Narrative Review: Stroke: Difference between revisions

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__NOTOC__
{{Narrative Review}}
{{CMG}}; {{AE}}{{MJ}}


{| class="wikitable"
{| class="wikitable"
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!AE code
!AE code
|-
|-
|xxx
|XXX
|xxx
|XXX
|x
|X
|
|...
|xx/xx/xxxx
|MM/DD/YYYY
|xxx
|XXX
|}
|}


== Demographic / Medical history ==
==Diagnosis==
* [age] year old [gender]
'''Addmission date:''' MM/DD/YYYY
* '''Past Medical History:''' [eg. VHD, anticoagulant usage, diabetes, and CAD,.../ including date]
* '''Past Surgical History:''' [including date]


== Procedure ==
==== Symptoms: ====
* '''Index Procedure Date/Time''':  
O Loss of consciousness
** xx/xx/xxxx at xx:xx  [insert date and time]
* '''Index Procedure Detail''': 
** On xx/xx/xxxx at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
** Access site details
** The site reported that there were/were not procedural complication(s).


== Event(s) ==
O New focal neurological deficits '''[scale based on the NIH table]'''
'''Event (1):'''
* '''Site Reported Event Onset Date:''' xx/xx/xxxx


* '''Event summary''':
O Presence of hypoglycemia
** Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
** Important characteristics of the chief complaint such as severity, site, and duration.
** Other important symptoms related to the chief compliant.
** Physical assessment:
*** Vital signs
*** Positive physical examinations or related negative examinations.
'''Event (2):'''
*'''Site Reported Event Onset Date:''' xx/xx/xxxx
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
** Important characteristics of the chief complaint such as severity, site, and duration.
** Other important symptoms related to the chief compliant.
** Physical assessment:
*** Vital signs
*** Positive physical examinations or related negative examinations.


== Laboratory data, Imaging and tests ==
O Presence of AF (or other arrhythmia)
* '''Lab studies:'''
** Date/ name/ value


== Diagnostic tests ==
=== National Institutes of Health Stroke Scale: [Write the score of stroke] ===
* xx/xx/xxxx at xx:xx on brain MRI
{| class="wikitable"
* xx/xx/xxxx at xx:xx on MRA
!Class
* xx/xx/xxxx at xx:xx on CT
!Title
* xx/xx/xxxx at xx:xx on EEG
!Responses and Scores
* xx/xx/xxxx at xx:xx on Carotid US
|-
* xx/xx/xxxx at xx:xx on ECG:
|1A
|Level of consciousness
|0—Alert
1—Drowsy
 
2—Obtunded
 
3—Coma/unresponsive
|-
|1B
| colspan="1" rowspan="1" |Orientation questions
| colspan="1" rowspan="1" |0—Answers both correctly
1—Answers 1 correctly
 
2—Answers neither correctly
|-
| colspan="1" rowspan="1" |1C
| colspan="1" rowspan="1" |Response to commands
| colspan="1" rowspan="1" |0—Performs both tasks correctly
1—Performs 1 task correctly
 
2—Performs neither
|-
| colspan="1" rowspan="1" |2
| colspan="1" rowspan="1" |Gaze
| colspan="1" rowspan="1" |0—Normal horizontal movements
1—Partial gaze palsy
 
2—Complete gaze palsy
|-
| colspan="1" rowspan="1" |3
| colspan="1" rowspan="1" |Visual fields
| colspan="1" rowspan="1" |0—No visual field defect
1—Partial hemianopia
 
2—Complete hemianopia
 
3—Bilateral hemianopia
|-
| colspan="1" rowspan="1" |4
| colspan="1" rowspan="1" |Facial movement
| colspan="1" rowspan="1" |0—Normal
1—Minor facial weakness
 
2—Partial facial weakness
 
3—Complete unilateral palsy
|-
| colspan="1" rowspan="1" |5
| colspan="1" rowspan="1" |Motor function (arm)a. Leftb. Right
| colspan="1" rowspan="1" |0—No drift
1—Drift before 5 seconds
 
2—Falls before 10 seconds
 
3—No effort against gravity
 
4—No movement
|-
| colspan="1" rowspan="1" |6
| colspan="1" rowspan="1" |Motor function (leg)a. Leftb. Right
| colspan="1" rowspan="1" |0—No drift
1—Drift before 5 seconds
 
2—Falls before 5 seconds
 
3—No effort against gravity
 
4—No movement
|-
| colspan="1" rowspan="1" |7
| colspan="1" rowspan="1" |Limb ataxia
| colspan="1" rowspan="1" |0—No ataxia
1—Ataxia in 1 limb
 
2—Ataxia in 2 limbs
|-
| colspan="1" rowspan="1" |8
| colspan="1" rowspan="1" |Sensory
| colspan="1" rowspan="1" |0—No sensory loss
1—Mild sensory loss
 
2—Severe sensory loss
|-
| colspan="1" rowspan="1" |9
| colspan="1" rowspan="1" |Language
| colspan="1" rowspan="1" |0—Normal
1—Mild aphasia
 
2—Severe aphasia
 
3—Mute or global aphasia
|-
| colspan="1" rowspan="1" |10
| colspan="1" rowspan="1" |Articulation
| colspan="1" rowspan="1" |0—Normal
1—Mild dysarthria
 
2—Severe dysarthria
|-
| colspan="1" rowspan="1" |11
| colspan="1" rowspan="1" |Extinction or inattention
| colspan="1" rowspan="1" |0—Absent
1—Mild (loss 1 sensory modality lost)
 
2—Severe (loss 2 modalities lost)
|}
 
==== Imaging: ====
* '''MM/DD/YYYY at xx:xx on brain MRI''' : [Write the MRI findings, '''mention the site of stroke''' here]
* '''MM/DD/YYYY at xx:xx on brain CT''' : [Write the CT findings, '''mention the site of stroke''' here]
* '''MM/DD/YYYY at xx:xx on EEG''':
* '''MM/DD/YYYY at xx:xx on Carotid US:'''
 
==== Type of stroke/TIA: ====
O '''Ischemic Stroke'''
 
O '''Hemorrhagic Stroke'''
 
O '''Undetermined Stroke'''
 
O '''TIA'''
 
== Stroke/TIA definitions ==
 
=== Stroke: ===
Each of:
* Duration of a focal or global neurological deficit 24 h
 
* < 24 h if available neuroimaging procedure (CT scan or brain MRI) documents a new intracranial or subarachnoid hemorrhage (hemorrhagic stroke) or central nervous system infarction (ischemic stroke) 
* The neurological deficit results in death
 
* There is confirmation of a stroke diagnosis by a neurologist or neurosurgical specialist.
 
==== Ischemic: ====
* An acute episode of focal cerebral, spinal, or retinal dysfunction caused by infarction of the central nervous system tissue.
 
==== Hemorrhagic: ====
* An acute episode of focal or global cerebral or spinal dysfunction caused by intraparenchymal, intraventricular, or subarachnoid hemorrhage.
 
==== Undetermined: ====
* If there is insufficient information to allow categorization as ischemic or hemorrhagic.
 
=== TIA: ===
Each of:
* Duration of a focal or global neurological deficit <24 h and neuroimaging procedure (CT scan or brain MRI) does not demonstrate a new hemorrhage or infarct.
* There is confirmation of a TIA diagnosis by a neurologist or neurosurgical specialist.
 
==Event==
'''Demographic:''' [age] year old [gender]
 
'''Site Reported Event Onset Date:''' MM/DD/YYYY
 
'''Event (1) summary''':
*'''Symptoms and sign''':
**Subject presented with [sign and symptom] on MM/DD/YYYY.
**Important characteristics of the chief complaint such as severity, site, and duration.
**Other important symptoms related to the chief complaint.
 
*'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
*'''Past Surgical History:''' [including date]
*'''Medications:''' [relevant to the event not all]
*'''Physical assessment:'''
**Vital signs
**Positive physical examinations or related negative examinations.
'''Event (2) summary: [If there is more than 1 event]'''
*'''Symptoms and sign''':
**Subject presented with [sign and symptom] on MM/DD/YYYY.
**Important characteristics of the chief complaint such as severity, site, and duration.
**Other important symptoms related to the chief complaint.
 
*'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
*'''Past Surgical History:''' [including date]
*'''Medications:''' [relevant to the event not all]
*'''Physical assessment:'''
**Vital signs
**Positive physical examinations or related negative examinations.
==Procedure==
*'''Index Procedure Date/Time''':
**MM/DD/YYYY at xx:xx [insert date and time]
*'''Index Procedure Detail''':
**On MM/DD/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
**Access site details
**The site reported that there were/were not procedural complication(s). 
== Laboratory data ==
* '''Lab studies list:''' (Date/ name/ value)
 
== Other Diagnostic tests ==
* MM/DD/YYYY at xx:xx on MRA: [write the most important findings]
* MM/DD/YYYY at xx:xx on ECG: [write the most important findings]


* xx/xx/xxxx at xx:xx on ECHO:
* MM/DD/YYYY at xx:xx on ECHO: [write the most important findings]
* xx/xx/xxxx at xx:xx on Ultrasound:  
* MM/DD/YYYY at xx:xx on Ultrasound: [write the most important findings]
* xx/xx/xxxx at xx:xx on Endoscopy:  
* MM/DD/YYYY at xx:xx on Endoscopy: [write the most important findings]
* xx/xx/xxxx at xx:xx ... (Other relevant imaging and diagnostic tests)  
* MM/DD/YYYY at xx:xx ... (Other relevant imaging and diagnostic tests)  
== Consults==
==Consults==
*Date and time of consult
*Date and time of consult
*Suggested treatments
*Suggested treatments
Line 74: Line 240:
==Treatment and outcome==
==Treatment and outcome==
*List of relevant medical treatments
*List of relevant medical treatments
*Out come [Discharge / Hospice / Death]
*Outcome [Discharge / Hospice / Death]

Latest revision as of 00:29, 27 June 2018

Narrative Review

Narrative Review: Death

Narrative Review: Stroke

Narrative Review: Myocardial Infarction

Narrative Review: Acute Kidney Injury

Narrative Review: Bleeding

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Site Patient AE Complication Event date AE code
XXX XXX X ... MM/DD/YYYY XXX

Diagnosis

Addmission date: MM/DD/YYYY

Symptoms:

O Loss of consciousness

O New focal neurological deficits [scale based on the NIH table]

O Presence of hypoglycemia

O Presence of AF (or other arrhythmia)

National Institutes of Health Stroke Scale: [Write the score of stroke]

Class Title Responses and Scores
1A Level of consciousness 0—Alert

1—Drowsy

2—Obtunded

3—Coma/unresponsive

1B Orientation questions 0—Answers both correctly

1—Answers 1 correctly

2—Answers neither correctly

1C Response to commands 0—Performs both tasks correctly

1—Performs 1 task correctly

2—Performs neither

2 Gaze 0—Normal horizontal movements

1—Partial gaze palsy

2—Complete gaze palsy

3 Visual fields 0—No visual field defect

1—Partial hemianopia

2—Complete hemianopia

3—Bilateral hemianopia

4 Facial movement 0—Normal

1—Minor facial weakness

2—Partial facial weakness

3—Complete unilateral palsy

5 Motor function (arm)a. Leftb. Right 0—No drift

1—Drift before 5 seconds

2—Falls before 10 seconds

3—No effort against gravity

4—No movement

6 Motor function (leg)a. Leftb. Right 0—No drift

1—Drift before 5 seconds

2—Falls before 5 seconds

3—No effort against gravity

4—No movement

7 Limb ataxia 0—No ataxia

1—Ataxia in 1 limb

2—Ataxia in 2 limbs

8 Sensory 0—No sensory loss

1—Mild sensory loss

2—Severe sensory loss

9 Language 0—Normal

1—Mild aphasia

2—Severe aphasia

3—Mute or global aphasia

10 Articulation 0—Normal

1—Mild dysarthria

2—Severe dysarthria

11 Extinction or inattention 0—Absent

1—Mild (loss 1 sensory modality lost)

2—Severe (loss 2 modalities lost)

Imaging:

  • MM/DD/YYYY at xx:xx on brain MRI : [Write the MRI findings, mention the site of stroke here]
  • MM/DD/YYYY at xx:xx on brain CT : [Write the CT findings, mention the site of stroke here]
  • MM/DD/YYYY at xx:xx on EEG:
  • MM/DD/YYYY at xx:xx on Carotid US:

Type of stroke/TIA:

O Ischemic Stroke

O Hemorrhagic Stroke

O Undetermined Stroke

O TIA

Stroke/TIA definitions

Stroke:

Each of:

  • Duration of a focal or global neurological deficit 24 h
  • < 24 h if available neuroimaging procedure (CT scan or brain MRI) documents a new intracranial or subarachnoid hemorrhage (hemorrhagic stroke) or central nervous system infarction (ischemic stroke)
  • The neurological deficit results in death
  • There is confirmation of a stroke diagnosis by a neurologist or neurosurgical specialist.

Ischemic:

  • An acute episode of focal cerebral, spinal, or retinal dysfunction caused by infarction of the central nervous system tissue.

Hemorrhagic:

  • An acute episode of focal or global cerebral or spinal dysfunction caused by intraparenchymal, intraventricular, or subarachnoid hemorrhage.

Undetermined:

  • If there is insufficient information to allow categorization as ischemic or hemorrhagic.

TIA:

Each of:

  • Duration of a focal or global neurological deficit <24 h and neuroimaging procedure (CT scan or brain MRI) does not demonstrate a new hemorrhage or infarct.
  • There is confirmation of a TIA diagnosis by a neurologist or neurosurgical specialist.

Event

Demographic: [age] year old [gender]

Site Reported Event Onset Date: MM/DD/YYYY

Event (1) summary:

  • Symptoms and sign:
    • Subject presented with [sign and symptom] on MM/DD/YYYY.
    • Important characteristics of the chief complaint such as severity, site, and duration.
    • Other important symptoms related to the chief complaint.
  • Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
  • Past Surgical History: [including date]
  • Medications: [relevant to the event not all]
  • Physical assessment:
    • Vital signs
    • Positive physical examinations or related negative examinations.

Event (2) summary: [If there is more than 1 event]

  • Symptoms and sign:
    • Subject presented with [sign and symptom] on MM/DD/YYYY.
    • Important characteristics of the chief complaint such as severity, site, and duration.
    • Other important symptoms related to the chief complaint.
  • Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
  • Past Surgical History: [including date]
  • Medications: [relevant to the event not all]
  • Physical assessment:
    • Vital signs
    • Positive physical examinations or related negative examinations.

Procedure

  • Index Procedure Date/Time:
    • MM/DD/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On MM/DD/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s). 

Laboratory data

  • Lab studies list: (Date/ name/ value)

Other Diagnostic tests

  • MM/DD/YYYY at xx:xx on MRA: [write the most important findings]
  • MM/DD/YYYY at xx:xx on ECG: [write the most important findings]
  • MM/DD/YYYY at xx:xx on ECHO: [write the most important findings]
  • MM/DD/YYYY at xx:xx on Ultrasound: [write the most important findings]
  • MM/DD/YYYY at xx:xx on Endoscopy: [write the most important findings]
  • MM/DD/YYYY at xx:xx ... (Other relevant imaging and diagnostic tests)

Consults

  • Date and time of consult
  • Suggested treatments

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
  • Outcome [Discharge / Hospice / Death]